GUIDE
Editors
Joseph F. Hagan, Jr, MD, FAAP
Judith S. Shaw, RN, MPH, EdD
Paula M. Duncan, MD, FAAP
FUNDED BY
CITE AS
Hagan JF, Shaw JS, Duncan P, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents, Third Edition. Pocket Guide. Elk Grove Village, IL: American Academy of Pediatrics.
Copyright 2008 by the American Academy of Pediatrics. All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
Library of Congress Catalog Card Number: 2007929964
ISBN-13: 978-1-58110-224-6
ISBN-10: 1-58110-224-0
BF0027
PUBLISHED BY
TABLE OF CONTENTS
Bright Futures at the American Academy of Pediatrics. . . . . . . . . v
How to Use This Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Core Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Building Effective Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Fostering Family-Centered Communication . . . . . . . . . . . . . . . . . . . xi
Promoting Health and Preventing Illness. . . . . . . . . . . . . . . . . . . . . . xii
Managing Time for Health Promotion . . . . . . . . . . . . . . . . . . . . . . . xiii
Educating Families Through Teachable Moments . . . . . . . . . . . . . . xiv
Advocating for Children, Families, and Communities . . . . . . . . . . . xv
Supporting Families Successfully . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Children and Youth With Special Health Care Needs . . . . . . . . . . . xvii
Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Complementary and Alternative Care . . . . . . . . . . . . . . . . . . . . . . xviii
Bright Futures Themes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Bright Futures Health Supervision Visits . . . . . . . . . . . . . . . . . . . . 1
Acronyms Used in the Bright Futures Health Supervision Visits. . . . . 1
Prenatal Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Newborn Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
First Week Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
6 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
9 Month Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
12 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
15 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
18 Month Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2 12 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4 Year Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5 and 6 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
7 and 8 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
9 and 10 Year Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Early Adolescence (11 to 14 Year Visits) . . . . . . . . . . . . . . . . . . . . . 42
Middle Adolescence (15 to 17 Year Visits). . . . . . . . . . . . . . . . . . . . 46
Late Adolescence (18 to 21 Year Visits) . . . . . . . . . . . . . . . . . . . . . . 50
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Developmental Milestones at a Glance Infancy . . . . . . . . . . . . . 54
Developmental Milestones at a Glance Early Childhood . . . . . . 55
Social and Emotional Development in Middle Childhood . . . . . . . . 56
Domains of Adolescent Development . . . . . . . . . . . . . . . . . . . . . . . 57
Recommended Medical Screening Infancy . . . . . . . . . . . . . . . . . 58
Recommended Medical Screening Early Childhood . . . . . . . . . . 59
Recommended Medical Screening Middle Childhood . . . . . . . . 60
Recommended Medical Screening Adolescence . . . . . . . . . . . . 61
Tooth Eruption Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Sexual Maturity Ratings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Useful Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
iii
vii
Appendices: Includes developmental milestones at-aglance charts for infancy and early childhood, a chart on
social and emotional development in middle childhood,
a chart on domains of adolescent development,
recommended medical screening tables, a tooth eruption
chart, a sexual maturity ratings chart, and a list of useful
Web sites.
viii
Core Concepts
A summary of each of these core concepts is presented on the following pages to help all professionals, both
those in training and experienced practitioners, bring
Bright Futures alive and make it happen for children and
families. For more information about this unique health
promotion curriculum, visit www.pediatricsinpractice.org.
All 6 core concepts rely on the health care professionals skills in using open-ended questions to communicate
effectively, partner with and educate children and their
families, and serve as their advocates to promote health
and prevent illness in a time-efficient manner.
Open-ended questions
Help to start a conversation
Ask: Why? How? What?
n Are interpretive
n Have a wide range of possible answers
n Stimulate thinking
n Promote problem solving
n
n
EXAMPLES:
Techniques
n
EXAMPLE:
ix
1. Model and encourage open, supporting communication with child and family.
n Integrate family-centered communication strategies.
n Use communication skills to build trust, respect, and
empathy.
xi
EXAMPLES:
Take time for self and partner for leisure and exercise.
Encourage partner to help care for child.
Accept support from friends, family.
EXAMPLE:
How often and for how long do you breastfeed the baby? How
do you know when he wants to be fed?
n
EXAMPLE:
Note:
n If parent hesitates with an answer, try to determine the
reason.
n If parent brings in child multiple times for minor
problems, explore the possibility of another unresolved
concern.
xii
4. Come to closure.
n Be sure that the health message is understood.
EXAMPLES:
EXAMPLE:
Tell me about the babys sleeping habits. What position does she
sleep in? (Elicits more than yes/no answer and presents teachable moment on back to sleep and sudden infant death syndrome.)
xiii
xiv
TEACHING STRATEGIES
ADVANTAGES
Is this issue of interest to anyone else (eg, school/early intervention teacher, local policy makers)? Who (or what) might oppose
the advocacy efforts? Why?
EXAMPLE:
What are some of the main concerns in your life right now?
n
EXAMPLE:
EXAMPLE:
EXAMPLE:
EXAMPLE:
3. Develop a strategy.
n Limit efforts to a specific issue.
EXAMPLE:
4. Follow through.
n Be passionate about the issue, but willing to negotiate.
n Review the outcome.
n Evaluate your efforts.
n Determine next steps with family.
n Recognize that health care professionals and families
can learn from one another about effective advocacy.
xv
xvii
xviii
number of themes are of key importance to families and health care professionals in their common mission to promote the health and
well-being of children from birth through adolescence.
These themes are:
xix
AAP
ATV
BMI
CBE
CDC
CPR
DVD
HIV
IEP
OTC
SMR
STI
TV
WIC
Screening
Discuss the purpose and importance of the newborn
screening tests (metabolic, hearing) that will be done in
the hospital before the baby is discharged.
Immunizations
Anticipatory Guidance
FA M I LY R E S O U R C E S
Your familys health values/beliefs/practices are important to the health of your baby.
What health practices do you follow to keep your family healthy?
2
Key= Guidance for parents, questions
PA R E N TA L ( M AT E R N A L ) W E L L - B E I N G
BREASTFEEDING DECISION
Anticipatory Guidance
FA M I LY R E A D I N E S S
What makes you get upset with the baby? What do you do when
you get upset?
Key= Guidance for parents, questions
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Tell me about your living situation. What are your resources for
caring for the baby?
I N FA N T B E H AV I O R S
FEEDING
Exclusive breastfeeding during the first 4-6 months provides ideal nutrition, supports best growth and development; iron-fortified formula is recommended substitute;
recognize signs of hunger, fullness; develop feeding
routine; adequate weight gain = 6-8 wet diapers a day,
no extra fluids; cultural/family beliefs.
If breastfeeding: 8-12 feedings in 24 hours; continue
prenatal vitamin; avoid alcohol.
If formula feeding: Prepare/store formula safely; feed
every 2-3 hours; hold baby semi-upright; dont prop
bottle.
Contact WIC/community resources if needed.
Are you concerned about having enough money to buy food for
yourself or infant formula?
SAFETY
Surveillance of Development: Is able to sustain periods of wakefulness for feeding, will gradually become
able to establish longer stretch of sleep (4-5 hours at
night); turns and calms to parents voice, communicates
needs through behaviors, has undifferentiated cry; is able
to fix briefly on faces or objects, follows face to midline;
is able to suck/swallow/breathe, shows strong primitive
reflexes, lifts head briefly in the prone position.
Anticipatory Guidance
PA R E N TA L ( M AT E R N A L ) W E L L - B E I N G
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
How is the adjustment to the new baby going? Are there times
when you feel sad, hopeless, or overwhelmed?
NEWBORN TRANSITION
Exclusive breastfeeding during the first 4-6 months provides ideal nutrition, supports best growth and development; iron-fortified formula is recommended substitute;
recognize signs of hunger, fullness; develop feeding
routine; adequate weight gain = 6-8 wet diapers a day,
no extra fluids; cultural/family beliefs.
How do you know if your baby is hungry? Had enough to eat?
NEWBORN CARE
Anticipatory Guidance
PA R E N TA L ( M AT E R N A L ) W E L L - B E I N G
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
FA M I LY A D J U S T M E N T
Do you always feel safe in your home? Has your partner or expartner ever hit you? Are you scared that you or other caretakers
may hurt the baby? Would you like information on where to go
and who to contact for help?
SAFETY
Car safety seats, toys with loops and strings, falls, tobacco
smoke
10
Anticipatory Guidance
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
PA R E N TA L ( M AT E R N A L ) W E L L - B E I N G
I N FA N T B E H AV I O R
What do you and your partner enjoy most about your baby? What
is challenging?
11
12
Anticipatory Guidance
FA M I LY F U N C T I O N I N G
Immunizations
DC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
What do you think your baby is trying to tell you when she cries,
looks at you, turns away, smiles?
What do you do to calm your baby? Do you ever feel that you or
other caretakers may hurt the baby? How do you handle that feeling?
O R A L H E A LT H
Put baby to sleep on back; dont use loose, soft bedding; lower crib mattress before baby can sit up;
choose mesh playpen with weave < 41 "; never leave
baby in with drop side down.
Use quiet (reading, singing) and active (tummy time)
playtime; provide safe opportunities to explore.
Continue calming strategies when fussy.
13
Anticipatory Guidance
FA M I LY F U N C T I O N I N G
14
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
I N FA N T D E V E L O P M E N T
Parent expectations (parents as teachers), infant developmental changes (cognitive development/learning, playtime),
communication (babbling, reciprocal activities, early
intervention), emerging infant independence (infant selfregulation/behavior management), sleep routine (selfcalming/putting self to sleep, crib safety)
How does your baby communicate or tell you what he wants and
needs?
O R A L H E A LT H
15
16
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Anticipatory Guidance
FA M I LY A D A P TAT I O N S
I N FA N T I N D E P E N D E N C E
Self-feeding, mealtime routines, transition to solids (tablefood introduction), cup drinking (plans for weaning)
17
18
Anticipatory Guidance
Make time for self and partner; time with family; keep
ties with friends.
Maintain or expand ties to your community; consider
parent-toddler playgroups, parent education, or support group.
FA M I LY S U P P O RT
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
E S TA B L I S H I N G R O U T I N E S
SAFETY
E S TA B L I S H I N G A D E N TA L H O M E
19
20
Anticipatory Guidance
C O M M U N I C AT I O N A N D S O C I A L D E V E L O P M E N T
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
How does your child communicate what she wants? Does she
point to something she wants and then watch to see if you see
what shes doing?
SLEEP ROUTINES AND ISSUES
SAFETY
Some conflict/tantrums can be avoided by toddlerproofing home, using distractions, accepting messiness, allowing child to choose (when appropriate).
When did you last examine your home to make sure it is safe?
What emergency numbers do you have posted near your phones?
T E M P E R TA N T R U M S A N D D I S C I P L I N E
21
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Anticipatory Guidance
FA M I LY S U P P O RT
22
Key= Guidance for parent, questions
SAFETY
Car safety seats; parental use of safety belts; falls, fires, and
burns; poisoning; guns
LANGUAGE PROMOTION/HEARING
C H I L D D E V E L O P M E N T A N D B E H AV I O R
23
Observation of Parent-Child Interaction: How do parent and child communicate? What is tone of the interaction and the feelings conveyed? Does child feel free to
explore the room? How does the parent set limits?
Surveillance of Development: Imitates adults, plays
alongside other children, refers to self as I or me,
has at least 50 words, uses 2-word phrases, asks parent
to read a book; follows 2-step commands, completes
sentences and rhymes in familiar books; stacks 5 or 6
blocks, makes or imitates horizontal and circular strokes
with crayon, turns pages one at a time, imitates food
preparation, throws ball overhand; goes up and down
stairs one step at a time, jumps up.
circumference. Calculate and plot BMI, or plot weightfor-length. Examine for red reflexes. Perform cover/
uncover test. Observe for caries, plaque, demineralization, staining, injury, gingivitis. Observe running,
scribbling, socialization, ability to follow commands.
Assess language acquisition/clarity.
Immunizations
Physical Exam. Complete, including: Measure standing height (preferred) or recumbent length, weight, head
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Anticipatory Guidance
24
Key= Guidance for parent, questions
TELEVISION VIEWING
T E M P E R A M E N T A N D B E H AV I O R
25
26
Surveillance of Development: Play includes other children; has fears about unexplained changes in environment/unexpected events; uses phrases of 3-4 words, is
understandable to others 50% of the time; knows the
correct action for animal or person (eg, bird flies, man
talks), points to 6 body parts; jumps up and down in
place, throws ball overhand, brushes teeth with help,
puts on clothes with help, copies vertical line.
Anticipatory Guidance
FA M I LY R O U T I N E S
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Encourage family exercise (walking, swimming, biking).
Tell me how you have fun with your family.
SAFETY
27
Anticipatory Guidance
FA M I LY S U P P O RT
28
Key= Guidance for parent, questions; Guidance for child, questions
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Tell me how family members show affection, anger? Describe what
your family does together.
SAFETY
How does your child tell you what he wants? How well does the
family understand his speech?
P L AY I N G W I T H P E E R S
Encourage play with appropriate toys and safe exploration; fantasy play.
Tell me about your childs typical play.
Limits on inactivity
29
30
Anticipatory Guidance
SCHOOL READINESS
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
How does your child communicate what she wants and knows?
D E V E L O P I N G H E A LT H Y P E R S O N A L H A B I T S
Limit TV and video to 1-2 hours a day; no TV in bedroom; watch programs together and discuss.
Make opportunities for daily play; be physically active as
a family.
CHILD AND FAMILY INVOLVEMENT AND SAFETY IN THE COMMUNITY
31
Observation of Parent-Child Interaction: How do parent and child interact with health care professional? How
do parent and child interact? Does parent have realistic
expectations about child?
Surveillance of Development: Balances on one foot,
hops, and skips; able to tie a knot. Shows school readiness skills: has mature pencil grasp, can draw a person
with at least 6 body parts, prints some letters and
numbers, is able to copy squares and triangles, has good
articulation/language skills, counts to 10, names 4+
colors, follows simple directions, listens and attends.
Immunizations
Anticipatory Guidance
SCHOOL READINESS
32
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
M E N TA L H E A LT H
33
Observation of Parent-Child Interaction: How do parent and child interact? Does parent have realistic expectations about child? How does child interact with adults
other than parents?
Surveillance of Development:
Physical, cognitive, emotional, social, moral
competencies
Caring, supportive relationship with family, other adults,
peers
8 Year Visit
Universal: Vision; Hearing
Selective: Anemia; Tuberculosis; Dyslipidemia
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
34
Key= Guidance for parent, questions; Guidance for child, questions
7 Year Visit
Universal: None
Selective: Vision; Hearing; Anemia; Tuberculosis
Immunizations
SCHOOL
Encourage competence/independence.
What new things have you tried recently?
Anticipatory Guidance
35
O R A L H E A LT H
36
Key= Guidance for parent, questions; Guidance for child, questions
Surveillance of Development:
Physical, cognitive, emotional, social, and moral competencies
Behaviors that promote wellness and contribute to a
healthy lifestyle
Caring, supportive relationship with family, other adults,
and peers
Sense of self-confidence and hopefulness
Increasingly responsible and independent decision
making
38
Key= Guidance for parent, questions; Guidance for child, questions
9 Year Visit
Universal: None
Selective: Vision; Hearing; Anemia; Tuberculosis
10 Year Visit
Universal: Vision; Hearing
Selective: Anemia; Tuberculosis; Dyslipidemia
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
SCHOOL
Anticipatory Guidance
Be physically active 60 minutes a day; limit nonacademic screen time to 2 hours a day.
How often do you go outside and play?
39
O R A L H E A LT H
SAFETY
40
Key= Guidance for parent, questions; Guidance for child, questions
Remove guns from home; if gun necessary, store unloaded and locked with ammunition separate.
Homicide and completed suicide are more common in homes with
guns. Have you considered not owning a gun because it poses a
danger to the family?
What have your parents taught you about guns and gun safety?
42
Observation of Parent-Youth Interaction: How comfortably do youth and parent interact? Who asks and
answers most questions? Does youth express interest in
managing his own health?
Surveillance of Development:
Physical, cognitive, emotional, social, and moral
competencies
Behaviors that contribute to a healthy lifestyle
Caring, supportive relationship with family, other adults,
and peers
Positive engagement with community
Self-confidence, hopefulness, well-being, and resiliency
when confronted with life stressors
Increasingly responsible and independent decision
making
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Clearly communicate rules/expectations/family responsibilities; spend time with your youth, get to know
friends.
Stay connected with family; follow family rules and
curfews.
Anticipatory Guidance
43
44
Remove guns from home; if gun necessary, store unloaded and locked with ammunition locked separately.
45
46
Key= Guidance for youth, questions; Guidance for parent, questions
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
Anticipatory Guidance
47
48
Do you have someone you can call for a ride if you feel unsafe
riding with someone?
Remove guns from home; if gun necessary, store unloaded and locked with ammunition locked separately;
keep key inaccessible to youth.
Manage conflict nonviolently; avoid risky situations;
healthy dating relationships are built on respect and
doing things you both like to do; saying NO is okay.
Teach nonviolent conflict-resolution techniques.
49
50
Key= Guidance for young adult, questions
Immunizations
CDC: www.cdc.gov/vaccines
AAP: www.aapredbook.org
EMOTIONAL WELL-BEING
Anticipatory Guidance
51
52
Key= Guidance for young adult, questions
APPENDICES
Appendices
53
2 Months
4 Months
6 Months
9 Months
GROSS MOTOR
FINE MOTOR
COGNITIVE, LINGUISTIC,
AND COMMUNICATION
SOCIAL-EMOTIONAL
Head up 45
Lift head
Roll over
Sithead steady
Sitno support
Roll over
Pull to stand
Stand holding on
Laugh
Vocalize
Turn to rattling sound
Laugh
Turn to voice
Turn to rattling sound
Dada/Mama, nonspecific
Single syllables
Smile spontaneously
Smile responsively
KEY
Black: 50% to 90% of children pass this item.
Green: More than 90% of children pass this item.
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
54
GROSS MOTOR
FINE MOTOR
COGNITIVE, LINGUISTIC,
AND COMMUNICATION
SOCIAL-EMOTIONAL
1 Year
Stand alone
Pull to stand
Imitate vocalizations/sounds
Babbling*
1 word
Protodeclarative pointing*
Wave bye-bye
Imitate activities
Play pat-a-cake
15 Months
Walk backwards
Stoop and recover
Walk well
Scribble
Put block in cup
1 word*
3 words
18 Months
Walk up steps
Run
Walk backwards
Remove garment
Help in house
2 Years
Tower of 6 cubes
Tower of 4 cubes
Name 1 picture
Combine words
Point to 2 pictures
Put on clothing
Remove garment
212 Years
Know 2 actions
Speech half understandable
Point to 6 body parts
Name 1 picture
3 Years
Name friend
Brush teeth with help
4 Years
Hop
Balance on each foot
2 seconds
Define 5 words
Name 4 colors
Speech all understandable
KEY
Black: 50% to 90% of children pass this item.
Green: More than 90% of children pass this item.
*Absence of this milestone should trigger screening for autism.
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
55
Self
Family
Friends
School
Community
56
KEY AREAS (Key areas in italics are especially important for children with special health care needs.)
Self-esteem:
Experiences of success
Reasonable risk-taking behavior
Resilience and ability to handle failure
Supportive family and peer relationships
Self-image:
Body image, celebrating different body images
Prepubertal changes; initiating discussion about sexuality and reproduction; prepubertal changes related to physical care issues
What matters at home:
Expectation and limit setting
Family times together
Communication
Family responsibilities
Family transitions
Sibling relationships
Caregiver relationships
Friendships:
Making friends, friendships with peers with and without special health care needs
Family support of friendships, family support to have typical friendship activities, as appropriate
School:
Expectation for school performance, school performance/defined in the Individualized Education Program
Homework
Child-teacher conflicts, building relationships with teachers
Parent-teacher communication
Ability of schools to address the needs of children from diverse backgrounds
Awareness of aggression, bullying, and victimization
Absenteeism
Community strengths:
Community organizations
Religious groups
Cultural groups
High-risk behaviors and environments:
Substance use
Unsafe friendships
Unsafe community environments
Particular awareness of risk-taking behaviors and unsafe environments, because children may be easily victimized
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
MIDDLE ADOLESCENCE
(15 TO 17 YEARS)
LATE ADOLESCENCE
(18 TO 21 YEARS)
Physiological
Growth completed
Psychological
Social
Potential
Problems
Source: See the Child Development theme in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.
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ACTION
Metabolic and
hemoglobinopathy
Development
Oral health
Hearing
SELECTIVE
ACTION IF RA +
Blood pressure
Blood pressure
Hearing
Anemia
Lead
Tuberculosis
Vision
1W
1M
2M
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NB
4M
6M
9M
NB
1W
1M
2M
4M
6M
9M
Ophthalmology referral
Development
Autism
Vision
Hearing
Anemia
Lead*
SELECTIVE
ACTION IF RA +
Oral health
No dental home
Blood pressure
Ophthalmology referral
Blood
pressure
Vision
Hearing
Anemia
Lead
Lead
Tuberculosis
Dyslipidemia
12M
15M
18M
2Y
2 12Y
UNIVERSAL
3Y
4Y
12M
15M
18M
2Y
2 12Y
3Y
4Y
*Universal lead screen = high prevalence area or on Medicaid; Beginning at age 3, blood pressure becomes part of the physical examination; Selective lead screen = low prevalence area and not on Medicaid.
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Vision
Hearing
SELECTIVE
Oral health
Vision
Hearing
Anemia
Lead
Tuberculosis
Dyslipidemia
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ACTION
Objective measure with age-appropriate visual acuity measurement (using HOTV; tumbling
E tests; Snellen letters; Snellen numbers; or Picture tests, such as Allen figures or LEA symbols)
Snellen test
Audiometry
RISK ASSESSMENT (RA)
ACTION IF RA +
No dental home
Primary water source deficient in fluoride
+ on risk screening questions
+ on risk screening questions
+ on risk screening questions
No previous screen and + on risk
screening questions or change in risk
+ on risk screening questions
+ on risk screening questions and not
previously screened with normal results
5Y
6Y
5Y
6Y
7Y
8Y
9Y
7Y
10Y
8Y
9Y
10Y
Pregnancy
Cervical dysplasia
Alcohol or drug use
ACTION
Snellen test
EARLY
(11-14Y)
MIDDLE
(15-17Y)
LATE
(18-21Y)
EARLY
(11-14Y)
MIDDLE
(15-17Y)
LATE
(18-21Y)
ACTION IF RA +
Snellen test
Audiometry
Hemoglobin or hematocrit
Tuberculin skin test
Lipid screen
*The CDC has recently recommended universal voluntary HIV screening for all sexually active people, beginning at age 13. At the time of publication, the AAP and other groups had not yet commented on the CDC recommendation, nor recommended screening criteria or techniques. The health care professionals attention is drawn to the voluntary nature of screening and that the CDC allows an opt out in communities where the HIV rate is
<0.1%. The management of positives and false positives must be considered before testing.
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Permanent Dentition
Primary Dentition
D.E. F. G.
H.
C.
I.
B.
J.
A.
K.
T.
S.
L.
M.
R.
Q. P. O.N.
Upper Teeth
Erupt
Exfoliate
Upper Teeth
Erupt
Central incisor
8-12 months
6-7 years
Central incisor
7-8 years
Lateral incisor
9-13 months
7-8 years
Canine (cuspid)
16-22 months
10-12 years
First molar
13-19 months
9-11 years
Second molar
25-33 months
10-12 years
Lower Teeth
Erupt
Exfoliate
Second molar
23-31 months
10-12 years
First molar
14-18 months
9-11 years
6.
5.
4.
3.
7. 8. 9. 10.
11.
12.
13.
2.
15.
1.
16.
Canine (cuspid)
17-23 months
9-12 years
32.
17.
Lateral incisor
10-16 months
7-8 years
31.
18.
Central incisor
6-10 months
6-7 years
30.
19.
20.
21.
28.
27. 24. 22.
26.25.23.
29.
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14.
Source: Reproduced with permission from the Arizona Department of Health Services, Office of Oral Health, courtesy of Don Altman, DDS, MPH.
The assistance of the American Dental Hygienists Association is gratefully acknowledged.
Lateral incisor
8-9 years
Canine (cuspid)
11-12 years
10-11 years
10-12 years
First molar
6-7 years
Second molar
12-13 years
17-21 years
Lower Teeth
Erupt
17-21 years
Second molar
12-13 years
First molar
6-7 years
10-12 years
10-11 years
Canine (cuspid)
11-12 years
Lateral incisor
8-9 years
Central incisor
7-8 years
The developmental stages of the adolescents sexual characteristics should be rated separately (ie, one stage for
pubic hair and one for breasts in females, one stage for
pubic hair and one for genitals in males), because these
characteristics may differ in their degree of maturity.
SMR
PUBIC HAIR
SMR
PUBIC HAIR
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
None
Scanty, long, slightly pigmented, primarily at base of penis
Darker, courser, starts to curl, small amount
Course, curly; resembles adult type but covers smaller area
Adult quantity and distribution, spread to medial surface of thighs
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
None
Sparse, slightly pigmented, straight, at medial border of labia
Darker, beginning to curl, increased amount
Course, curly, abundant, but amount less than in adult
Adult feminine triangle, spread to medial surface of thighs
SMR
GENITALS
SMR
BREASTS
Stage 1
Stage 2
Preadolescent
Breast and papilla elevated as small mound; areolar diameter
increased
Breast and areola enlarged, no contour separation
Areola and papilla form secondary mound
Mature; nipple projects, areola part of general breast contour
Stage 1
Stage 2
PENIS
TESTES
Preadolescent
Slight enlargement
Preadolescent
Slight enlargement of testes and
scrotum; scrotal skin reddened,
texture altered
Further enlargement of testes and
scrotum
Further enlargement of testes and
scrotum
Adult
Stage 3
Longer
Stage 4
Larger in breadth,
glans penis develops
Adult
Stage 5
Stage 3
Stage 4
Stage 5
Source: Tables have been adapted with permission from Daniels1(p29) (as drawn from Tanner2); see also Spear.3(p4)
References
1. Daniels WA. Adolescents in Health and Disease. St Louis, MO: Mosby, Inc; 1977
2. Tanner JM. Growth at Adolescence. 2nd ed. Oxford, England: Blackwell Scientific Publications; 1962
3. Spear B. Adolescent growth and development. In: Rickert VI, ed. Adolescent Nutrition: Assessment and Management. New York, NY: Chapman and Hall (Aspen Publishers, Inc); 1996:3-24
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64
US Department of Labor
http://jobcorps.doleta.gov
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